Stage III Uterine Cancer

Overview

Stage III uterine cancer extends outside the uterus, but remains confined to the pelvis. Stage IIIA cancers invade the lining of the pelvis or fallopian tubes or cancer cells can be found free in the pelvis. Stage IIIB cancer invades the vagina. Stage IIIC cancers invade the pelvic and/or para-aortic lymph nodes.

A variety of factors ultimately influence a patient's decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient's chance of cure, or prolong a patient's survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

The following is a general overview of the treatment of stage III uterine cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.

Optimal treatment of patients with stage III uterine cancer often requires more than one therapeutic approach. Thus, it is important for patients to be treated at a medical center that can offer multi-modality treatment involving gynecologic oncologists and radiation oncologists. Survival following treatment of stage III uterine cancer is determined by the extent of spread of the cancer and the ability of the surgeon to remove all visible cancer.

Surgery

In general, primary treatment of women with stage III uterine cancer is surgery. Women with stage III uterine cancer usually have a hysterectomy (removal of the uterus), bilateral salpingo-oophorectomy (removal of the ovaries), and pelvic lymph node dissection with or without removal of the para-aortic lymph nodes. The surgeon will attempt to remove as much cancer as possible without causing major side effects. Unfortunately, some women with stage III uterine cancer cannot have all the cancer removed, especially when the cancer extends to the wall of the pelvis.

Following standard treatment with a total abdominal hysterectomy, a majority of patients will experience recurrence of their cancer. This is because many patients with stage III cancer have microscopic cancer cells (micrometastases) that have spread outside the uterus and therefore were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. The presence of these micrometastases causes recurrence following treatment with surgery alone. Following surgery, patients may benefit from additional treatment (adjuvant therapy) to decrease the risk of cancer recurrence. There is a progressive increase in local and distant cancer recurrences in patients with well, moderately and poorly differentiated cancers following treatment with surgery alone. To learn more about surgery, go to Surgery & Uterine Cancer.

Adjuvant Radiation Therapy

Patients with stage III uterine cancer who have complete surgical removal of all cancer are candidates for adjuvant radiation therapy. The objective of adjuvant radiation therapy is to kill cancer cells that persist after surgery for a maximum probability of cure with a minimum of side effects. Radiation is usually given in the form of high-energy beams that deposit the radiation dose in the body where cancer cells are located (external beam radiation therapy) or is delivered directly to the cancer by placing an isotope in the area of the cancer (brachytherapy). Radiation therapy, unlike chemotherapy, is considered a local treatment. Cancer cells can only be killed where the actual radiation is delivered to the body. If cancer exists outside the radiation field, the cancer cells are not destroyed by the radiation. Treatment of stage III uterine cancer with surgery followed by adjuvant brachytherapy and/ or external beam radiation therapy has been reported to cure approximately 50% of patients.

Despite adjuvant radiation therapy, many patients will experience a cancer recurrence. Further treatment with systemic hormonal and/or chemotherapy, instead of or in addition to radiation therapy, may be required to further decrease the risk of cancer recurrence in patients with stage III cancer.

Radiation Therapy as Primary treatment

Strategies to Improve Treatment

The progress that has been made in the treatment of stage III uterine cancer has resulted from improved doctor and patient participation in clinical studies. Future progress in the treatment of stage III uterine cancer will result from continued participation in appropriate studies. Currently, there are several areas of active exploration aimed at improving the treatment of recurrent uterine cancer.

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed. For more information, go to Supportive Care.

Adjuvant Chemotherapy: Since patients treated with surgery and radiation therapy may develop a cancer recurrence outside the pelvis, adjuvant therapy that can reach and destroy these cancer cells may improve treatment. However, there have been no meaningful comparative studies of adjuvant chemotherapy for the prevention of recurrences in patients with stage III uterine cancer. Patients with advanced uterine cancer do respond to hormonal agents and to various combinations of chemotherapy including drugs such as doxorubicin, Platinol® and paclitaxel. Clinical trials are ongoing to evaluate drug combinations of Platinol®, paclitaxel, or doxorubicin for adjuvant therapy alone or in combination with radiation.

Adjuvant Hormonal Therapy: Progestational agents have long been used in the treatment of advanced or recurrent uterine cancer because some cancer cells respond to treatment. Well-differentiated cancers respond better to progestational agents than undifferentiated cancers. Clinical trials are ongoing to evaluate hormonal therapy administered alone or in combination with chemotherapy, surgery and/or radiation therapy.

Adjuvant Chemotherapy and Hormonal Therapy: Recently, researchers in Greece have evaluated a four-drug combination of Paraplatin®, methotrexate, fluorouracil and medroxyprogesterone. These physicians treated 23 patients with advanced or recurrent uterine cancer. None of the patients had received prior chemotherapy or hormonal therapy and 10 had received prior radiation therapy. Responses were observed in 74% of women, with two long-lasting complete remissions. The average duration of response was over 10 months and the average survival was over 16 months. This regimen was administered on an outpatient basis and was well tolerated. These doctors concluded that this was an active treatment regimen for women with advanced or recurrent uterine cancer. It would be logical to evaluate such drug combinations with hormonal therapy for prevention of recurrences in women with stage III uterine cancer treated with surgery.

Improved Staging: Undetected spread of cancer can lead to under-treatment of uterine cancer. One method for detecting the spread of cancer is examination of cells floating free in the peritoneum (pelvis). This is done by injecting a salt solution into the abdomen, allowing it to mix thoroughly and then removing it for examination under the microscope. However, it is sometimes difficult to distinguish normal cells from cancer cells when using this method.

Monoclonal antibodies are proteins that can locate cancer cells and bind to them, thereby enabling the pathologist to better distinguish cancer cells from normal cells. The use of monoclonal antibodies to identify cancer cells in the peritoneum may improve the accuracy of staging and help identify patients requiring more aggressive treatment.

Gene Therapy: Currently, there are no gene therapies approved for the treatment of uterine cancer. Gene therapy is defined as the transfer of new genetic material into a cell for therapeutic benefit. This can be accomplished by replacing or inactivating a dysfunction gene or replacing or adding a functional gene into a cell to make it function normally. Gene therapy has been directed towards the control of rapid growth of cancer cells, control of cancer death or efforts to make the immune system kill cancer cells. A few gene therapy studies may be carried out in women with advanced or recurrent uterine cancer.